Safer Sex: Information for Counselors (Part VIII)

References - Condoms

Sex Behavior

(Arranged Chronologically)

Assessing the stages of change and decision-making for contraceptive use for the prevention of pregnancy, sexually transmitted diseases, and acquired immunodeficiency syndrome.

Grimley DM. et al.
Health Educ Q. 1993 Winter;20(4):455-70.

A synergistic approach was taken to examine contraceptive use adoption for two related behaviors: pregnancy prevention and the prevention of sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). One hundred twenty-three young adults responded to questionnaire items based on two constructs from the Trans-theoretical Model of Change, the Stages of Change and Decisional Balance, as well as other pertinent variables. In Phase 1, two Decisional Balance measures were developed: One for the prevention of pregnancy and one for disease prevention. Final versions of both measures consisted of two 10-item scales: one representing the positive aspects (PROS) and one representing the negative aspects (CONS) of contraceptive and condom use. In Phase 2, the same individuals were staged for both pregnancy and disease prevention according to their readiness to change for contraceptive and condom use. MANOVAs and ANOVAs indicated that the PROS and CONS for both measures were related to stage of change for both contraceptive and condom use. Results from this pilot study were consistent with prior applications of the Trans-theoretical Model to the cessation of such problem behaviors as smoking and to the adoption of positive health behaviors such as exercise acquisition.

Gender differences in AIDS-relevant condom attitudes and condom use.

Sacco WP. et al.
AIDS Educ Prev. 1993 Winter;5(4):311-26.

Two studies, conducted approximately one year apart, examined gender differences in AIDS-relevant condom attitudes, condom use behaviors, and relationships among attitudes and condom use behaviors. Subjects (N = 248, N = 528) were undergraduates, primarily heterosexual. Females reported more favorable attitudes, with the exception of greater inhibition about buying and possessing condoms. Men engaged in preliminary condom use behaviors (carrying and keeping condoms at home) substantially more often than did women. Preliminary condom use behaviors predicted past and intended condom use more consistently for men than for women. Relationships between condom attitudes and condom use behaviors were generally similar for both sexes, with poorer self-control explaining the most variance in past and intended condom use. These results, interpreted from the perspective of Eagly's (1987) gender role theory, suggest that although females may indirectly influence condom use decisions, providing condoms is the expected role of males, infusing them with greater control over the interpersonal process.

Condom use: a self-efficacy model.

Wulfert E. et al.
Health Psychol. 1993 Sep;12(5):346-53.

A survey of heterosexually active college students gathered information about condom use, self-efficacy (SE), outcome expectancies, sexual attitudes, peer group influences, acquired immunodeficiency syndrome (AIDS) knowledge, and perceived vulnerability to AIDS. On the basis of A. Bandura's (1986) social-cognitive theory, a structural model with SE as the central mediator was formulated and evaluated with LISREL. This model explained 46% of the variance in condom use from judgments of SE and effects attributable to peers and 53% of the variance in SE from outcome expectancies and peer group influences. Sexual attitudes, AIDS knowledge, and perceived vulnerability did not predict condom use. Most students were well-informed about human immunodeficiency virus (HIV) transmission but reported not feeling at risk, even though many engaged in risky sexual behavior.

U.S. Young adults have lots of sex, lots of partners, yet refuse to use condoms: the National AIDS Behavioral Surveys.

Binson D. et al.
Int Conf AIDS. 1993 Jun 6-11;9(2):690 (abstract no.

OBJECTIVE: To assess prevalence and demographic correlates of high risk sexual behavior among young heterosexual adults in the USA. METHODS: The National AIDS Behavioral Surveys (NABS: N = 10,630) is a national probability sample of US residents (response rate = 70%) and a probability sample of urban residents in 23 major cities with high AIDS prevalence (High Risk Cities sample: response rate = 65%). We examined prevalence and demographic correlates of AIDS-related risk behaviors among young adults. 18 to 25 years of age, (n = 1,201) in the High Risk Cities (54% white, 24% African American, 17% Latino American, 5% other ethnic groups). RESULTS: 30% of young adults engaged in risky behavior over the last 12 months and only 20% of these used condoms consistently. 65% engaged in risky behavior over the last 5 years. The breakdown by risk factor (behaviors assessed for last year) for men and women at risk is shown below: TABULAR DATA, SEE ABSTRACT VOLUME. Men, the unmarried, and those 18 and 19 were the most likely to have multiple sex partners. Among Whites and African Americans, young people with education beyond high school were more likely to have multiple partners than those with less education. Of those with multiple sex partners, approximately 40% never used condoms with either primary or secondary partners. As the number of secondary partners increased, condom use decreased. CONCLUSION: In the US, prevention proposals targeted at young adults typically tie protection from AIDS to monogamous commitment. These fail to capture the realities of young adults and are bound to fail. Even worse, these messages are misleading because monogamy for young adults is short-lived.

Widespread condom use by seropositive injecting drug users with non-injector sexual partners.

Friedman SR. et al.
Int Conf AIDS. 1993 Jun 6-11;9(2):691 (abstract no.

OBJECTIVE: To assess whether condom use by injecting drug users (IDUs) differs by HIV serostatus and/or by sex partner (SP) characteristics. METHODS: 293 street-recruited New York IDUs (69% male) were HIV tested and asked about their relationships with up to 10 SPs each. Analyses focus on condom use during the prior 30 days in 386 sexual partnerships. 28 linked pairs of IDUs who are each others' SPs were compared for data validation. RESULTS: 35% of respondents were seropositive. 25 of 28 (89%) linked pairs agreed on the proportion of sex acts in which they used condoms. Always using condoms is reported in 33% (128/386) of relationships. The table shows proportions of relationships in which condoms are always used: TABULAR DATA, SEE ABSTRACT VOLUME. In multivariate logistic regression controlling for gender, closeness of relationship, and other variables, condoms are always used more in relationships between seropositive IDUs and non-IDU SPs than in other relationships (odds ratio = 4.59; 95% CI = 1.57, 13.41). CONCLUSIONS: Condom use by IDUs in New York, with its relatively mature epidemic, is concentrated where it may most reduce the spread of HIV to non-IDU heterosexuals--in relationships between infected IDUs and non-IDU partners. This may reflect IDUs' altruism and/or non-IDU SPs' pressure; prevention projects should build upon both. Mathematical modelers should incorporate differential condom use by serostatus and partner's drug use.

Low level of always condom use with either partners among bisexual males engaging in penetrative sexual practices with female and male partners.

Sasse H. et al.
Int Conf AIDS. 1993 Jun 6-11;9(2):819 (abstract no.

OBJECTIVES: To compare, in bisexual males, penetrative sexual practices (PSP) in 1991 with female partners to PSP with male partners. METHODS: Participants of this multicenter study, conducted in public gay meeting places in 17 italian cities during the period Nov. 1991-Jan. 1992, were homosexual and bisexual males. Males reporting in 1991 female and male partners were classified as bisexuals. Always using condoms during PSP was considered protected behavior and not always or never condom use unprotected behavior. Data analyses were performed using Epi-info and BMDP programs. RESULTS: Among the 1227 participants, 451 (37%) men had had female and male partners during life-time, and 241 (20%) during 1991. Of these 241 bisexuals, 40% were 25 years old or younger, and either two thirds had had the first sexual contact with male (164, 68%) and female partners (160, 66%) until the age of 20 years. 100 (42%) BI engaged in 1991 at least once a week in male-to-male sex and 76 (32%) in male-to-female sex (p < 0.05). 75/94 (80%) BI engaged in PSP with steady male partners, 172/209 (82%) with non-steady male partners and 173/241 (72%) with female partners. Among them, proportions of unprotected PSP was lower with non-steady male partners (73, 42%) than with steady male partners (56, 75%) and than with female partners (121, 70%) (p = < 0.05). 38/170 (22%) BI engaging in PSP with either female and male partners reported always using condoms with either partners. There was low agreement between protected and unprotected PSP with either partners among BI engaging in PSP with female and with non-steady male partners (125/170, 74%) (K-statistics: K = 0.22, 95% CI: 0.06-0.38). 38/51 (75%) BI using always condoms with female partners reported even always using condoms with non-steady male partners, instead of 38/90 (42%) BI for the opposite condition (p < 0.05). CONCLUSIONS: One fourth of bisexuals engaging in 1991 in penetrative sexual practices PSP with female and male partners reported always using condoms with either partners. Conditions that favour greater condom use with female partners may have an important role for HIV prevention.

Sex, AIDS, and the use of condoms: a survey of compliance in college students.

Oswalt R. et al.
Psychol Rep. 1993 Jun;72(3 Pt 1):764-6.

To evaluate compliance with the suggestion that condoms be used during risky sexual activity, 206 college students' use of condoms during genital and anal sex was surveyed. Analysis indicated that 78% engaged in genital intercourse, and while 20% always used a condom, 44% used condoms less than half the time. Of the 10% engaged in anal sex, 90% did not use condoms. Students at highest risk (with the most partners) were using condoms least often. All respondents reported knowing AIDS was transmitted sexually. Nonetheless, reasons given for not using condoms were belief they knew their partners' sexual history or another form of birth control was being used. Results suggest that outcome studies are needed to assess programs which focus on behavioral change, including use of condoms.

Sexual issues and condom use among injecting drug users.

White D. et al.
AIDS Care. 1993;5(4):427-37.

Recent surveys of injecting drug users reveal that their injecting behaviours have changed in the light of HIV, but their sexual behaviours have not and, in particular, they remain reluctant to use condoms to reduce the risks of sexual transmission. In an attempt to explore this issue further the present study assessed the behaviours and attitudes of injecting drug users to sexual issues, including condom use. Condom use was low. Obstacles to their use included for some a desire to conceive, for many a belief in their infertility, a perceived invulnerability to HIV infection through their sexual behaviour patterns, a dislike of condoms and difficulty in negotiating condom use with partners. The lifestyle of drug users may also have an influence on condom use. Many drug users funded their habit through illegal activities including prostitution, theft and fraud. The association between these and other factors and condom use are explored.

Use of condoms by heterosexually active drug abusers before and after AIDS education.

McCusker J. et al.
Sex Transm Dis. 1993 Mar-Apr;20(2):81-8.

This study identified variables associated with increased condom use among drug abusers in a randomized trial of three AIDS educational programs in a short-term inpatient detoxification program. Participants (n = 301) completed baseline and follow-up interviews and were heterosexually active on both occasions. At baseline, 10% always, 24% sometimes, and 66% never used condoms, and this distribution changed only slightly at follow-up. Among the latter two groups, 21% increased their use. There was no differential intervention effect on changes in condom use. Women, but not men, were more likely to initiate condom use than to increase to consistent use with all partners, and to initiate use if they had multiple partners. Although beneficial attitudes and beliefs about condoms were more common among women at baseline, positive changes in these attitudes/beliefs were associated with increased condom use among men only. Among men, personal attitudes and beliefs were associated with increased condom use, while among women, perceptions of the attitudes of sexual partners were more important.

Sexual behaviors of African-American male college students and the risk of HIV infection.

Johnson RL. et al.
J Natl Med Assoc. 1992 Oct;84(10):864-8.

A survey of the rates of sexually transmitted diseases and protective sexual behaviors among a population of African-American male college students demonstrates that although monogamy, avoidance of casual sexual activity, and the avoidance of the use of drugs and alcohol during sexual activity tends to decrease the risk of exposure to human immunodeficiency virus, consistent condom use is the only sexually related behavior that is significantly protective.

Inappropriate lubricant use with condoms by homosexual men.

Martin DJ
Public Health Rep. 1992 Jul-Aug;107(4):468-73.

Use of condoms has been advocated as an important method of reducing the risk of human immunodeficiency virus (HIV) transmission among high-risk groups such as homosexual and bisexual men, prostitutes, intravenous drug users, adolescents, and hemophiliacs. Despite risk-reduction education campaigns directed to gay men since the early 1980s, evidence shows continued deficits in condom-use skills and knowledge among gay men. Because most failures in the use of condoms are attributed to errors in use, increasing knowledge and skills in condom use is important in preventing HIV infection. Two groups of homosexual and bisexual men were sampled, those entering a risk-reduction education program and participants in a Gay Pride event. They were surveyed on their current sex practices and their efforts to reduce their risk of HIV infection. They were asked about their numbers of sex partners, specific sexual behaviors, use of condoms, types of condoms used, and lubricants used for genital-anal sex. The characteristics of those surveyed were similar to those of respondents in other studies of risk reduction among gay men. The use of an oil-based lubricant with condoms has been shown to weaken latex and to increase the likelihood of condom breakage, which use of water-based lubricants does not. Among respondents who reported having genital-anal sex, 60 percent reported use of an oil-based lubricant with a condom at least once during the year before the survey. Gay men in sexually exclusive relationships engaged in less consistent use of condoms for receptive genital-anal sex than did single gay men.(ABSTRACT TRUNCATED AT 250 WORDS)

Condom use in U.S. Hispanic men with multiple female partners.

Gomez CA. et al.
Int Conf AIDS. 1992 Jul 19-24;8(3):168 (abstract no. PuC

OBJECTIVE: To describe condom use and its predictors in Hispanic men with multiple female sexual partners. METHOD: In nine states of the U.S. with high proportions of Hispanics, a stratified clustered random telephone sampling strategy was used to identify Hispanic households. Interviews of 968 Hispanic males, aged 18 to 49 were conducted resulting in 521 (53.8%) men who reported having one female partner and 371 (38.3%) men with more than one female partner in the prior 12 months. Frequency of condom use with steady and causal partners in the 12 months prior to the interview was measured on a 5-point always-never scale. RESULTS: Among Hispanic men with multiple female partners, 60% reported always using condoms with their casual partners while only 18% always used with their steady partner. Carrying condoms, self-efficacy to use condoms, positive attitude towards use, having friends who used, and lack of depression in the two weeks prior to the interview predicted casual condom use (R2 = .35), whereas drug and alcohol use before sex did not. Comfort with sex significantly predicted carrying condoms, attitude toward use, and self-efficacy to use them. CONCLUSION: High rates of condom use with causal partners among high risk Hispanic heterosexual men suggest that programs to promote condom use with casual partners can succeed with this population. These programs should address the specific skills 1 needed to carry and use a condom with a causal partner, and increase comfort with sexuality in general.

Changes in condom use among homosexual men in San Francisco.

Catania JA. et al.
Health Psychol. 1991;10(3):190-9.

Employed data from two longitudinal surveys of gay men in San Francisco (a) to examine for cohort (Study 1) and attrition (Studies 1 and 2) bias effects on reported changes in condom use by gay men and (b) to investigate predictors of condom use (Study 2). Substantial increases in condom use were observed, and these changes were unrelated to attrition and cohort bias. In terms of predictors of condom use, men who always used condoms had higher levels of social support from informal sources of help, had more positive expectations that condoms would have positive interpersonal and personal consequences, and were more likely to be HIV positive than men who used condoms occasionally or never. The results are discussed in terms of their implications for HIV-prevention research.

Attitudes toward condom use and AIDS among patients from an urban family practice center.

Stewart DL. et al.
J Natl Med Assoc. 1991 Sep;83(9):772-6.

As part of an effort to better educate patients about using condoms, a survey was done to assess the sexual practices, attitudes toward acquired immunodeficiency syndrome (AIDS) and condom use by patients who visit an urban family practice center. A self-administered questionnaire was given to 126 patients of whom the majority were black and single. Seventeen percent indicated they had sex with more than one person in the 3 months before the survey. Within the last 5 years, 10% had sex with an intravenous drug abuser, and 6% with someone of the same sex. Fifty percent believed that condoms decrease sexual pleasure for men and 31% thought condoms made sex inconvenient. Twenty-seven percent of those surveyed believed that a man's penis may be too large for a condom and 18% believed that uncircumcised men could not use condoms. Forty-five percent believed they should be screened for human immune deficiency virus exposure. The results highlight attitudes and beliefs that may function as barriers to condom use and should be addressed when encouraging condom use with this population.

The association of AIDS education with sexual behavior and condom use for teenage men in the United States.

Ku L. et al.
Int Conf AIDS. 1991 Jun 16-21;7(2):419 (abstract no.

OBJECTIVE: This paper analyzes the association of the receipt of AIDS education (formal instruction about AIDS, mostly in schools) with the number of partners, frequency of intercourse and condom use for a national sample of teenage men. METHODS: The 1988 National Survey of Adolescent Males conducted in-person interviews with a nationally representative sample of 1,880 American men 15 to 19 years old. RESULTS: In preliminary multivariate analyses, those with formal instruction about AIDS report (1) increased condom use in the last year, (2) decreased in the frequency of intercourse in the last year (for older youth and those behind in school), and (3) depending on mode specification, either a reduction or no significant effect for the number of partners in the last year. Analyses also explore whether the associations of AIDS education with behaviors are mediated by differences in knowledge or attitudes about AIDS. DISCUSSION: The analysis indicates that AIDS education, as practiced across the U.S., was associated both with greater condom use and with reduced sexual activity. However, it cannot demonstrate a causal relationship. School-based AIDS instruction had no apparent adverse effects with respect to sexual activity.

Risk reduction among injecting drug users: changes in the sharing of injecting equipment and in condom use.

Klee H. et al.
AIDS Care. 1991;3(1):63-73.

In an investigation of risk behaviour among injecting drug users in the North-West of England, information was obtained concerning the sharing of injecting equipment, respondent's sexual partners and the use of condoms. Between six and nine months after the initial contact, 169 respondents (56%) were contacted again. The emphasis in the second phase of the project was on changes, if any, in risk behaviour that had occurred in the intervening period. Significant reductions were found in sharing, mostly in the more indiscriminate use of others' injecting equipment. No reduction was observed in sharing between injecting partners and little in sharing between close friends. The number of sexual partners had decreased and the use of condoms, although it increased among those involved in temporary relationships, remained low. Impediments to further progress in risk reduction are discussed.

Tailoring AIDS prevention: differences in behavioral strategies among heterosexual and gay bar patrons in San Francisco.

McKusick L. et al.
AIDS Educ Prev. 1991 Spring;3(1):1-9.

Three groups of San Francisco bar patrons (heterosexual men, heterosexual women, and gay men) were compared on four sexual risk reduction strategies for AIDS: safer sex practices (particularly adoption of the use of condoms), reducing the number of sexual partners, taking the HIV antibody test, and determining the characteristics of a potential sexual partner. Heterosexuals reported fewer sex partners and were more likely than gay men to interview potential partners. Gay men were more likely to use condoms and the HIV antibody test than their heterosexual counterparts. These findings encourage the design of interventions that take advantage of shaping and reinforcing strategies already in use in each group, and suggest when it is necessary to teach new strategies.

Factors influencing condom use in a sample of homosexually active men.

Fitzpatrick R. et al.
Genitourin Med. 1990 Oct;66(5):346-50.

A sample of 502 homosexually active men were recruited from genitourinary medicine clinics and non clinic sources and interviewed in relation to their sexual behaviour and factors that might influence their use of condoms. Three hundred and eighty three men (76%) reported penetrative anal sex in the previous year. Ninety four (25%) had not used condoms in penetrative sex. Failure to use condoms was associated with unfavourable attitudes to them, not knowing close friends or partners who had HIV-related health problems, having fewer sexual partners and being in a closed monogamous relationship. On the other hand levels of awareness about the risks of unprotected anal sex and involvement in gay networks and social groups were not predictors of condom use.

Preferred strategies for safe sex: relation to past and actual behaviour among sexually active men and women.

Gallois C. et al.
Int Conf AIDS. 1990 Jun 20-23;6(1):147 (abstract no.

OBJECTIVES: To determine the preferred sexual strategies for reducing risk of HIV infection among sexually active heterosexual men and women and homosexual men. To compare these preferences to past behaviour, intentions and behaviour at the next sexual encounter, using recent revisions of the Theory of Reasoned Action as a guide. METHODS: Five groups of sexually active respondents were examined: 55 male and 78 female heterosexual University students, aged 17 to 21 years; 85 male (mean age 27.4 years) and 85 female (26.7 years) heterosexuals, and 82 homosexual men (31.2 years), all from the general community. Respondents completed self-administered questionnaires about their past sexual practices, their intended practices for the next sexual encounter, their attitudes and norms about these practices, and their attitudes, norms, past history, and intentions about variables which increase or decrease the risk of HIV transmission by sexual means. Respondents completed and returned a follow-up questionnaire about their actual behaviour after their next sexual encounter. RESULTS: The majority of respondents in all five groups stated their preferred risk-reducing strategy as having sex only in an exclusive relationship; second choice of all groups was to use a condom. Respondents were then categorised into one of five strategies: (a) non-penetrative sex, (b) exclusive relationship plus condom use, (c) exclusivity without condom use, (d) non-exclusivity with condom use, (e) non-exclusivity without condom use. Results of ANOVAs and chi-square tests indicated that all heterosexual groups fell mainly into categories b and c, while homosexual men fell mainly into a and d, although minorities in all groups fell into the least safe category, e. Slippage into a less safe category from intentions to actual behaviour was less when intentions and past practice were congruent. Finally, path analyses indicated that past behaviour and intentions interacted to predict actual behaviour regarding condom use for all five groups. CONCLUSIONS: The sexual strategies of heterosexual men and women in terms of risk of HIV transmission are somewhat different from those of homosexual men, even though all groups state similar ideal strategies. Past behaviour is a strong predictor of actual sexual behaviour, because it acts to stabilise or weaken behavioural intentions. Past behaviour may also influence the extent to which resources for carrying out preferred strategies are available. These results have implications for the use of the Theory of Reasoned Action to predict sexual behaviour, as well as for safe sex education programmes aimed at heterosexuals and homosexuals.

Changes in the sexual behavior of HIV infected patients participating in a group process.

Rossi L. et al.
Int Conf AIDS. 1989 Jun 4-9;5:773 (abstract no. Th.D.P.88).

OBJECTIVE: To induce changes in the sexual behavior and use of condom as a preventive measure for diminishing HIV sexual transmission in a group of HIV seropositive homosexual men. METHODOLOGY: 36 seropositive, homosexual, asymptomatic, unmarried men, aged between 18 and 45 years old, requesting psychological support, were selected. The individuals were assigned to 3 groups: A (3 months), B (6 months), C (1 year), (90' session, 1 x wk). Several psychoanalytic group techniques, such as interpretation and free association, were used. Killing fantasies, incapability to establish total object relations, hostile feelings towards homosexuality, uncertainty of presenting clinical symptomatology and dying were interpreted in group sessions with the purpose of promoting condom use and modifying risky practices. Changes were evaluated at the end of all sessions. RESULTS: The results are presented in the following table: TABULAR DATA, SEE ABSTRACT VOLUME. DISCUSSION: 3 and 6 months groups were associated with changes in sexual behavior, the one year's group structural changes and in the condom's use.

Condom use among homosexual men.

Golombok S. et al.
AIDS Care. 1989;1(1):27-33.

A postal questionnaire survey of 262 homosexual men was carried out to investigate patterns of sexual behaviour and the use of condoms. Two hundred and twenty-nine of these subjects had been sexually active during the past year, with the mean number of male sexual partners being 8.09. One hundred and eighty men engaged in oral sex, and 117 ejaculated during this activity, of whom 103 (88%) did not use a condom. One hundred and sixteen men had engaged in insertive anal intercourse in the past year, and 102 had ejaculated during this activity. Of these, 32 did not use a condom. Some, however, only engaged in this activity within a monogamous relationship. The overall proportion of men who continued to engage in very high-risk sexual activity was small, however a different picture emerged if the sample was analysed in terms of the number of encounters with different men during the past year. Of the total estimated number of such encounters, almost half involved anal intercourse, and about half of these were unprotected. The reason for the apparent discrepancy is that those who continue to engage in high risk behaviour tend to be particularly sexually active.

Variables influencing condom use in a cohort of gay and bisexual men.

Valdiserri RO. et al.
Am J Public Health. 1988 Jul;78(7):801-5.

Nine hundred fifty-five of 1,384 (69 per cent) gay and bisexual men enrolled in a prospective study of the natural history of human immunodeficiency virus (HIV) infection who reported engaging in anal intercourse in the past six months were surveyed about condom use practices for both insertive (IAI) and receptive anal intercourse (RAI). The following results were obtained: 23 per cent of the men reported that they always used condoms for IAI and 21 per cent for RAI; 32 per cent sometimes used condoms for IAI; 28 per cent sometimes used condoms for RAI; 45 per cent never used condoms for IAI; and 50 per cent never used condoms for RAI. Multiple logistic regression analysis revealed that the following variables were associated with both insertive and receptive condom use: condom acceptability; a history of multiple and/or anonymous partners in the past six months, and the number of partners with whom one is high (drugs/alcohol) during sex. Knowledge of positive HIV serostatus was more strongly associated with receptive than with insertive use. Condom use is a relatively complex health-related behavior, and condom promotion programs should not limit themselves to stressing the dangers of unprotected intercourse.

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